All posts by krebse

Day 3 began with the news from Dr. Stephen Rulisa that PURE’s training program was approved yesterday as a certificate program from the National University of Rwanda! The trainees were happy to hear this as we got the training for the day underway with image based review in the library, “pass the pointer” style. This was a great way to get all the trainees active and engaged right off the bat, and we were pleased to see how quickly they are catching on. After review, Dr. Emmanuel from the Rwanda Society for Ultrasound joined us for Dave Mackenzie’s absorbing presentation on lung ultrasound. From there we moved into the conference room to start scanning away on each other to looking for (hopefully the absence of) pneumothoraces, pleural effusions or consolidations. We were happy to find that our trainees lungs were all in good shape, as are there growing ultrasound skills. We were very pleased to have Dr. Vincent from the MoH join us for a visit this afternoon during Megan Leo’s lecture on soft tissue and bone applications. After the last lecture of the day, we moved to the wards for scanning. We found plenty of pathology and wrapped up the afternoon with the entire group back together reviewing the images the various teams collected on the wards for more learning. We found multiple pericardial effusions, pneumonias, liver disease and ascites, an atrial thrombus, and plenty of B-lines. The trainees even diagnosed their first core pulmonale with a very large right ventricle, after just one Echo lecture with Dr. Leo. All are looking forward to our OB sessions tomorrow!

Tuesday September 2, 2012- PURE Training Day 2: Focus on IVC and Volume Status, and Echocardiography.

Today we began the second day of training with a hands-on scan review of FAST, which we taught and practiced with the trainees yesterday. This type of review seemed to be really useful for the trainees, their general attitude (as well as ours) is the more practice time they can get, the better. Considering how much information they were presented in one day, the trainees showed they had a pretty good grasp of the concepts and techniques, they were concentrated and engaged and they couldn’t get enough of it. Megan Leo presented a great Echo lecture, which was followed up again by small group practice focused on acquiring the different views and getting comfortable with the orientation. In the afternoon, we brought the portable machines into the wards in small trainee/trainer groups and scanned patients. We were excited to find lots of relevant pathology in the ER, Internal Medicine and Maternity wards- a few positive FAST exams, a pericardial effusion with severely depressed cardiac function, and a case of bilateral hydronephrosis. Scanning on patients definitely helped solidify the concepts for the trainees, and allow them to compare the normal images from practice to abnormal findings in the wards. To finish out the day, the PURE team had a nice family dinner – we know we have been working hard as two of us actually feel asleep at the table!

Emily Douglass has been a HUGE asset to PURE over the past year or so, and we’re lucky to have her on the ground in Rwanda for these next couple weeks. She is documenting her impressions of the intro course here

Monday September 3, 2012 – PURE Training Day 1

The PURE training team arrived to CHUK early Monday morning, to set up the lecture room in the Research Building that will serve as the PURE teaching headquarters for the length of the initial 2 week intensive training course. Six high quality ultrasound machines, generously donated for use by PURE for the duration of the training course, will be set up and used for hands-on education and practice throughout the training. The machines include 5 compact portable Mindrays; two DP-10, and three DP-50s, along with 5 curvilinear transducers, and 2 linear transducers provided by AfriChem. One non-portable Phillips machine was also provided for teaching, which has a curvilinear, linear, intracavitary and also a cardiac probe. The machines are brand new, in great condition, and their portability is excellent for the means of this course.

At 9 am the trainees arrived, and after coffee and after an introduction by Dr. Stephen Rulisa, head of research at CHUK, Dr. Henwood began by welcoming the physicians to the course and introducing the team of PURE trainers, Dr. Megan Leo, Dr. Josh Rempell, Dr. Raja Rao, Dr. David Mackenzie, and Dr. Sam Vallincourt, as well as the other members of the team involved in the program development: Dr. Damas Dukundane, Emily Douglass, and Benjamin Kabagambe. After Dr. Henwood’s introduction to the course and the schedule for the program in entirety, the physicians completed a two part baseline assessment, beginning with a questionnaire to assess their current level of experience with ultrasound prior to the training, as well as in what areas of training they have specific interest. The second part of the baseline assessment was a pre-training image based assessment, during which the trainees were shown a series of image based questions and asked to choose the answer based on their previous knowledge of the use of ultrasound.

After the baseline assessment, Dr. Rempell began the teaching with a lecture on Introduction to Point-of-Care Ultrasound, speaking a bit about Ultrasound use in emergency medicine and the role of bedside ultrasound in clinical practice. When asked about their prior training and ultrasound experience, the physicians indicated that they had received some training in medical school, and many of the physicians stated that they did currently use some applications of ultrasound in their practice. However, the trainees indicated a strong desire for more formal training in multiple applications. Dr. Rempell spoke about the importance of recognizing the strengths and limitations of POC ultrasound.

The next didactic session was given by our interventional radiologist, Dr. Raja Rao. He gave a great lecture on the physics and instrumentation of ultrasound. After a short lunch break, the application specific training kicked off with Dr. Rempell’s lecture on FAST protocol (Focused Assessment with Sonography in Trauma), which seeks to assess for the presence of abnormal collections of fluid within the abdomen. After the FAST didactic session, the trainees were put into small groups at practice stations each led by a trainer. The trainees then spent the remainder of the day practicing the FAST applications and getting comfortable with the machines and scanning techniques. The trainees showed excellent initiative and interest in learning and practicing the applications taught, and at the conclusion of the first day of the course the PURE team was impressed, and looking forward to continuing to work with such a capable and enthusiastic group of physicians.

I hope this newsletter finds you all well, things are going great here in Rwanda. I have been here now for a bit more than 2 weeks and while there have been ups and downs I can say without hesitation that we are making great progress towards making sure that things go as smoothly as possible after we launch the training on September 3rd.

Thank you to all of you wonderful folks who have volunteered your time and are generously supporting the cost of your own airfare! I sincerely hope that we find additional funds to pay everyone back, but for now this solution is letting us move forward. However, we can still use more trainers, especially during the months of October and November! PURE is covering in country transportation and lodging, and we will coordinate the details of your trip. Please reply to this email if you’re ultrasound trained and you’re interested in spending a couple weeks in beautiful Rwanda teaching your colleagues.

News wise, we ran into a problem in that the consideration we were to have from the Senate of the National University of Rwanda(NUR) didn’t happen as planned as they deferred any consideration of new programs due to a very full meeting agenda. We will be considered on August 5th. However, awaiting that decision will make it too late for us to plan properly for the training. Our solution is that we are running this training to launch in September as a Continuing Professional Development (CPD) course, and will upgrade the status to a course to qualify for an academic certificate from the NUR once that approval is complete. The general structure and content of the training will not change, nor will our research agenda, but doing this as CPD simplifies several factors.

While here in Rwanda we connected with leaders from the Kigali Health Institutes (KHI, trains allied health professions like ultrasound techs), the Rwandan Radiologic Society, and the Society for Ultrasound in Rwanda. As we are all institutions dedicated to ultrasound education, we thought to work together through the formation of a consortium or organizations all working on the same common goal. This will directly benefit PURE through greater local radiologist involvement for supervision and guidance as well as sharing of the responsibility for creation of a diploma in ultrasound for physicians as KHI has been assigned the same task. We also all thought that our cooperation would decrease duplication of efforts and provide a direct means for sharing resources and accessing funding opportunities we each individually may not have been eligible for. Most importantly, combining our efforts will better serve Rwandan healthcare practitioners and patients.

In the next couple weeks I hope to add some great detail to our website regarding the training curriculum, the agenda for trainers, info on lodging and transportation in Rwanda, and a map of our district hospitals with lots of other great details.

Any Rotarians on this list? This Wednesday evening I will be presenting PURE to the Kigali chapter of the Rotary. Their grants system is in the middle of some big changes, so I’m having a bit of trouble understanding where a grant to PURE would fall, but it would be great to make a connection between international chapters both interested in the same issue!

Trainers who will conduct the follow up visits to trainees will know this place well! Just 100 meters from a great hotel, this is the place to catch buses from Kigali to all over Rwanda and internationally. Enjoy the minute or so experience of navigating the area.

My sincere apologies for a lack of contact for the past 5 months, I hope this email finds all of you well. After submitting all of our applications for working in Rwanda and accreditation, there was a period of little news. After the news started to come, it was at first somewhat trying, and only in the past 3 weeks or so have things been looking up again and we are still on target to launch this pilot program in September!

The hurdles we ran into relate to some changes to our programming requested by the Rwandan Ministry of Health, specifically that we deliver a diploma level course rather than a certificate. For the past two months we have been discussing options with them, and we are now awaiting the formal decision of the Senate of the National University of Rwanda(NUR) regarding our proposed post-graduate certificate level training to start as a pilot this September. Pending their approval, the Hon. Minister will review our plans and with luck will give us the formal go ahead to move forward with this pilot-certificate, and we will direct our energy towards development of diploma level programs in the future if this will better fulfill the needs of the Ministry of Health. Though these discussion slowed our progress a bit, these events were not a true setback, as it has helped us to understand the needs and desires of Rwanda better, and illuminate a path towards future programming. Additionally, we have achieved accreditation as Continuing Professional Development (CPD) providers in Rwanda by the Rwanda Medical Council (RMC), the Faculty of Medicine has approved our plans, and both the Rwandan National Ethics Committee and and Partners IRB have approved our research plans. With all this in place, we believe that the NUR will approve our plans as well and the Hon. Minister will have everything in place that she needs to feel confident that this pilot-certificate program will serve Rwandan physicians well.

– We have created a calendar of time-periods during which we need ultrasound trainers to spend 2-3 weeks in Rwanda teaching our physician colleagues to use ultrasound at the bedside. If you feel you are qualified to teach, and interested in the travel, please contact me (krebse@gmail.com) to get a link to the Doodle calendar.

– PURE welcomes two new board members, Dr. Damas Dunkundane (A Rwandan GP, currently working at the PIH/Rwandan district hospital Butaro, who has extensive experience in local development projects, international speaking engagements, and a strong interest in ultrasound) and Dr. Raja Rao (A radiologist from Oregon, currently retired, who has been working on ultrasound training at Rwandan district level hospitals (and some radiology training as well) for the past two years.). Both have been invaluable to PURE so far and bring unique skills and experience to our board.

– Three talented Rwandese ultrasound technicians will be working with us while we are in country training physicians. With their incredible image acquisition skills they will help us to give as much hands on training to our trainees as possible.

– Curriculum building is going great, with almost all lectures completed and the focus now turning to creation of a teaching guide to standardize our delivery of the material to trainees, learning adjuncts, development of written and practical examinations, and surveys.

Just 3 months until we launch this pilot! Many of you were on this list from the very first emails back in Fall of 2010, so you can join me in thinking back to the humble beginnings of PURE (almost regrettably named PUER, French for ‘to stink’). Without the dedication and and tireless work of people like Trish Henwood, a PURE co-founder, this never could have come together. The door is always open for greater involvement amongst any of the rest of you, just let me know your interest. Thanks!

The link above will take you to the site that details the plans for Rwanda’s ambitious Human Resources in Health (HRH) plan to improve medical education and, consequently, the quality of healthcare. The gist of the HRH plan is that foreign educators will be brought in to begin trainings and as time passes knowledge will be transferred ultimately resulting in construction of a sustainable means for Rwanda to continue progressing independently. A big rush of foreign trainers at the outset, and at the end a group of skilled Rwandese able to take over as trainers. No need for me to explain the details here, the site is comprehensive and well organized and includes information for how to apply to get involved. As PURE is an NGO, and multi-institutional effort(not a single university) we are not able to be formally affiliated with the HRH plan. However, we are excited at the prospect of helping to incorporate ultrasound training into appropriate educational programs.